Medicaid Clarifies Coverage of Autism Treatment Medicaid covers “medically necessary” treatment, including speech-language services—but states have the final say. Bottom Line
Bottom Line  |   April 01, 2015
Medicaid Clarifies Coverage of Autism Treatment
Author Notes
  • Laurie Alban Havens, MA, CCC-SLP, is director of ASHA private health plans and Medicaid advocacy.
    Laurie Alban Havens, MA, CCC-SLP, is director of ASHA private health plans and Medicaid advocacy.×
Article Information
Speech, Voice & Prosodic Disorders / Special Populations / Autism Spectrum / Practice Management / Bottom Line
Bottom Line   |   April 01, 2015
Medicaid Clarifies Coverage of Autism Treatment
The ASHA Leader, April 2015, Vol. 20, 32-33. doi:10.1044/leader.BML.20042015.32
The ASHA Leader, April 2015, Vol. 20, 32-33. doi:10.1044/leader.BML.20042015.32
Does Medicaid cover speech-language services for people with autism spectrum disorder?
Yes, it covers any medically necessary services for children with ASD, according to communications from the Centers for Medicare and Medicaid Services last year. However, Medicaid does not endorse or require any one particular treatment for ASD.
The federal guidance and follow-up information emphasize that Medicaid-eligible treatments should address the specific service needs of any individual, including one with ASD, who needs speech-language and other services. Like all Medicaid-covered services for children, they must be medically necessary to treat, correct or reduce illnesses and conditions. Each state has its own definition of medical necessity, and may attach certain restrictions to physicians’ orders.
Some services may be covered under waivers that are used to test new or existing ways to deliver and pay for health care services in Medicaid and the Children’s Health Insurance Program. There are four primary types of waivers and demonstration projects. These include:
  • Section 1115 Research and Demonstration Projects that test new or existing approaches to financing.

  • Section 1915(b) Managed Care Waivers that use a managed care delivery system.

  • Section 1915(c) Home and Community-Based Services for services provided in the home and community rather than in an institution.

  • Concurrent Section 1915 (b) and 1915 (c) that may use both of these programs to provide services.

Medicaid must follow general federal guidelines, but implementation and specific coverage policies differ by state. CMS recently released a document that compiles all services and supports covered by Medicaid for people with ASD, “Autism Spectrum Disorders (ASD): State of the States of Services and Supports for People With ASD.” The 400-plus-page report offers comprehensive, state-specific information.
States differ in their coverage of ASD-related services in many respects. Here are some questions to consider:
  • Is there an age limit for who receives services?

  • Are there services for adults?

  • Are there different coverage levels depending on the age of the client—for example, early childhood, school-age or adolescent?

  • What happens if services are covered for a child and then the child “ages out” of a program? Are there tools in place to help the client transition from one program to another?

  • Are services limited to a particular type of treatment—for example, applied behavior analysis?

  • Are there restrictions on who is considered a qualified provider of services?

  • Is there a monetary limit/cap after which services are no longer covered, or a limit on the number of sessions that can be provided?

  • Is there an appeal procedure for getting additional coverage?

  • Do programs accept only a certain number of people per year? Are there waiting lists? If so, what is the waiting list process?

  • Are people with ASD part of a larger category of covered individuals?

Here are some examples of how states differ in their ASD coverage:
  • California covers people with ASD (children and adults), but does so under other programs for those with developmental disabilities, not under a specific autism program.

  • Georgia has more waivers—other than those previously described—that cover ASD-related services.

  • In Illinois, covered services are not determined by a person’s diagnosis or condition, but by the person’s needs. The Illinois guidance indicates that people with ASD typically need social/emotional-related treatment and speech-language pathology services, and it emphasizes that an ASD diagnosis by itself does not guarantee coverage or any particular type of service.

  • Maryland has a waiver specifically for people with ASD through age 21 that helps provide home- and community-based services.

As with any Medicaid program, a client’s ability to receive covered services depends on the state. And although federal guidelines call for any medically necessary treatments for Medicaid-eligible people with ASD, the service type, duration, frequency, intensity and other variables are different in each state. Check with your state’s Medicaid program for specific details.
How Do Private Insurers Cover Autism Treatment?

Private insurance may also cover ASD-related services. The National Conference of State Legislatures maintains a Web page dedicated to ASD coverage. A total of 37 states and the District of Columbia maintain laws related to ASD and insurance coverage, and at least 30 of them specifically require insurers to cover autism treatment. Some mandates name specific types of treatments, and some have limits similar to those of some Medicaid programs.

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April 2015
Volume 20, Issue 4